[An analysis of the "slippery slope" of assisted death]. / Pendiente resbaladiza de la muerte asistida en los Países Bajos, Bélgica y Colombia.

The study analyzes the phenomenon of the "slippery slope" of assisted death in The Netherlands, Belgium, and Colombia after the depenalization or legalization of this practice. Data analysis was performed reviewing the evidence published in scientific journals and in the governments' official reports. We verified a progressive broadening of the limits initially established by the law for the practice of assisted death in these three countries. This confirms the occurrence of the "slippery slope". Also, the exponential increase in the number of assisted deaths in these three countries after the legalization indirectly suggests the presence of the "slippery slope". An analysis of the anthropological and ethical implications of assisted death highlights that its moral assessment should not be exclusively based on consequentialist arguments. Also, a prudential interpretation of the slippery slope argument in the legal debate about assisted death should be incorporated. We conclude that the moral evaluation of assisted death cannot be exclusively grounded on its negative social consequences, but rather on the lack of respect for basic human values such as life and the intrinsic dignity of a person. The verification of the "slippery slope" in these three countries should be regarded as an alarm for an eventual legalization of euthanasia in Chile.

Pendiente resbaladiza de la muerte asistida en los Países Bajos, Bélgica y Colombia / An analysis of the "slippery slope" of assisted death

The study analyzes the phenomenon of the "slippery slope" of assisted death in The Netherlands, Belgium, and Colombia after the depenalization or legalization of this practice. Data analysis was performed reviewing the evidence published in scientific journals and in the governments' official reports. We verified a progressive broadening of the limits initially established by the law for the practice of assisted death in these three countries. This confirms the occurrence of the "slippery slope". Also, the exponential increase in the number of assisted deaths in these three countries after the legalization indirectly suggests the presence of the "slippery slope". An analysis of the anthropological and ethical implications of assisted death highlights that its moral assessment should not be exclusively based on consequentialist arguments. Also, a prudential interpretation of the slippery slope argument in the legal debate about assisted death should be incorporated. We conclude that the moral evaluation of assisted death cannot be exclusively grounded on its negative social consequences, but rather on the lack of respect for basic human values such as life and the intrinsic dignity of a person. The verification of the "slippery slope" in these three countries should be regarded as an alarm for an eventual legalization of euthanasia in Chile.

[A reflection about the ethical implications of telemedicine]. / Una reflexión ética sobre la telemedicina.

Recognizing the role of technology in the development of medicine and the impact of telecommunication advances, we reflect on the meaning and ethics of the use of Telemedicine, both in its general dimension for the use and distribution of knowledge, as well as in the delivery of health actions, scientific research, and data management. Teleconsultation is discussed in greater detail, analyzing its process and application, reviewing its possible advantages and disadvantages, from the point of view of providers and patients. We highlight the need to carry out an appropriate evaluation of each instance, from the point of view of both the patient and the professional who uses it. The importance of maintaining a doctor-patient relationship in agreement with the nature and practice of Medicine, respecting people's dignity, is emphasized. We mention the ethical conditions that must be bore in mind for the proper use of telemedicine. We discuss the eventual influence that this practice will have on the concept and practice of medical care, while suggesting the need to legislate on the matter.

Una reflexión ética sobre la telemedicina / A reflection about the ethical implications of telemedicine

Recognizing the role of technology in the development of medicine and the impact of telecommunication advances, we reflect on the meaning and ethics of the use of Telemedicine, both in its general dimension for the use and distribution of knowledge, as well as in the delivery of health actions, scientific research, and data management. Teleconsultation is discussed in greater detail, analyzing its process and application, reviewing its possible advantages and disadvantages, from the point of view of providers and patients. We highlight the need to carry out an appropriate evaluation of each instance, from the point of view of both the patient and the professional who uses it. The importance of maintaining a doctor-patient relationship in agreement with the nature and practice of Medicine, respecting people's dignity, is emphasized. We mention the ethical conditions that must be bore in mind for the proper use of telemedicine. We discuss the eventual influence that this practice will have on the concept and practice of medical care, while suggesting the need to legislate on the matter.

[Conscientious objection in medical actions]. / Objeción de conciencia y acciones de salud.

Conscientious Objection arises as a response to a regulation that is judged as immoral. Faced with a law that is considered unfair, the citizen can respond accepting it against his will, exercising conscientious objection on a personal level or, collectively reaching civil disobedience or revolutionary violence. This is an old discussion known since ancient Greece. The current enactment of laws that allow actions previously judged as crime, and that contravene medical tradition, reactivated the discussion about such objection. Some people, such as Savolescu, who denies the legitimacy of conscientious objection invoked by doctors, arguing that it is inefficient, leads to inequality and is inconsistent. He proposes that the values of these professionals can be tolerated privately but should not be determinant in the public sphere. These arguments are critically examined, mentioning pertinent answers from theoretical and practical points of view. We highlight that ethics should not differ in public and private spheres and the principles should be the same, but exercised in different fields. It is concluded that conscientious objection is acquiring legitimacy and that it is necessary to reflect on the underlying reasons that lead to invoke it. It should be considered a civilized resource against determinations of power that are considered to be an attempt against personal values and moral integrity.

Objeción de conciencia y acciones de salud / Conscientious objection in medical actions

Conscientious Objection arises as a response to a regulation that is judged as immoral. Faced with a law that is considered unfair, the citizen can respond accepting it against his will, exercising conscientious objection on a personal level or, collectively reaching civil disobedience or revolutionary violence. This is an old discussion known since ancient Greece. The current enactment of laws that allow actions previously judged as crime, and that contravene medical tradition, reactivated the discussion about such objection. Some people, such as Savolescu, who denies the legitimacy of conscientious objection invoked by doctors, arguing that it is inefficient, leads to inequality and is inconsistent. He proposes that the values of these professionals can be tolerated privately but should not be determinant in the public sphere. These arguments are critically examined, mentioning pertinent answers from theoretical and practical points of view. We highlight that ethics should not differ in public and private spheres and the principles should be the same, but exercised in different fields. It is concluded that conscientious objection is acquiring legitimacy and that it is necessary to reflect on the underlying reasons that lead to invoke it. It should be considered a civilized resource against determinations of power that are considered to be an attempt against personal values and moral integrity.

Espiritualidad en medicina: análisis de la justificación ética en Puchalski / Spirituality in medicine: an analysis of Christina Puchalki's writings

The relationship between spirituality and medicine is present from the very origins of Medicine. Its relevance has been rediscovered during the past decades. Numerous publications report positive health results when spiritual needs of patients are addressed. Authors like Edmund Pellegrino and Christina Puchalski have gained an acknowledged leadership in this field. The purpose of the article is to study Christina Puchalkis' contributions to the field, specifically through the identification and analysis of the ethical reasons that - according to Puchalski - justify the medical duty to provide spiritual care. As a result of our investigations, we propose to systematize the ethical reasons identified in Puchalski's writings in seven categories, that presuppose a broad definition of spirituality and a conception of "whole patient care". Our analysis shows that Puchalski's arguments are ultimately grounded on an ethics of virtue and a realist anthropology, more than in mere positive effects or in patient's wishes. Indeed, Puchaslki's anthropological conception recognized human dignity as an intrinsic value that must be always acknowledged, especially in the context of disease, where questions about the meaning of life, suffering, connection and transcendence inevitable arise. We conclude that Puchalski's ethical arguments are solid and suggest the challenge of including the spiritual dimension in the formation of health care professionals.

[Spirituality in medicine. An analysis of Christina Puchalki's writings]. / Espiritualidad en medicina: análisis de la justificación ética en Puchalski.

The relationship between spirituality and medicine is present from the very origins of Medicine. Its relevance has been rediscovered during the past decades. Numerous publications report positive health results when spiritual needs of patients are addressed. Authors like Edmund Pellegrino and Christina Puchalski have gained an acknowledged leadership in this field. The purpose of the article is to study Christina Puchalkis' contributions to the field, specifically through the identification and analysis of the ethical reasons that - according to Puchalski - justify the medical duty to provide spiritual care. As a result of our investigations, we propose to systematize the ethical reasons identified in Puchalski's writings in seven categories, that presuppose a broad definition of spirituality and a conception of "whole patient care". Our analysis shows that Puchalski's arguments are ultimately grounded on an ethics of virtue and a realist anthropology, more than in mere positive effects or in patient's wishes. Indeed, Puchaslki's anthropological conception recognized human dignity as an intrinsic value that must be always acknowledged, especially in the context of disease, where questions about the meaning of life, suffering, connection and transcendence inevitable arise. We conclude that Puchalski's ethical arguments are solid and suggest the challenge of including the spiritual dimension in the formation of health care professionals.

¿Tiene cabida, hoy, el "privilegio terapéutico"? / Does therapeutic privilege have a place in modern medicine?

During the last years, bioethical discussion has highlighted the role of the patients' autonomy, being informed consent its particular expression, about decisions that they should make about their own health. The Hippocratic tradition, the deontological positions of the Geneva Declaration of the World Medical Association and numerous codes of ethics in various countries, require that the physician, above all, should ensure patients' health. In this context the discussion on pros and cons for the so-called "therapeutic privilege" are discussed. The "therapeutic privilege" refers to the withholding of information by the clinician during the consent process in the belief that disclosure of this information would lead to harm or suffering of the patient. The circumstances and conditions in which this privilege can become valid are discussed. Special reference is made in order to respect multiculturalism and to the possibility of obtaining advice from health care ethics committees. The role of prudence in the doctor-patient relation must be highlighted. Disclosure of information should be subordinated and oriented to the integral well-being of the patient.

[Does therapeutic privilege have a place in modern medicine?] / ¿Tiene cabida, hoy, el "privilegio terapéutico"?

During the last years, bioethical discussion has highlighted the role of the patients' autonomy, being informed consent its particular expression, about decisions that they should make about their own health. The Hippocratic tradition, the deontological positions of the Geneva Declaration of the World Medical Association and numerous codes of ethics in various countries, require that the physician, above all, should ensure patients' health. In this context the discussion on pros and cons for the so-called "therapeutic privilege" are discussed. The "therapeutic privilege" refers to the withholding of information by the clinician during the consent process in the belief that disclosure of this information would lead to harm or suffering of the patient. The circumstances and conditions in which this privilege can become valid are discussed. Special reference is made in order to respect multiculturalism and to the possibility of obtaining advice from health care ethics committees. The role of prudence in the doctor-patient relation must be highlighted. Disclosure of information should be subordinated and oriented to the integral well-being of the patient.

[Some current threats to confidentiality in medicine]. / Algunas amenazas actuales a la confidencialidad en medicina.

Social, technical and legal conditions of the current practice of medicine make it necessary to insist on certain actions and circumstances that may jeopardize the confidentiality of information, offered by patients to their health providers. Therefore, some effects of the current Chilean law are analyzed in this respect, regarding access to data from the clinical record of a patient. Also, the risks of putting certain data on social networking sites are analyzed, as well as some of its effects on clinical practice. The reasons because of mandatory reporting of diseases, meaning danger to public health, is allowed, are mentioned. We also discuss the difficulties involved in managing the results of preventative health screenings and its knowledge by third parties, as well as some possible violations of personal privacy, regarding dissemination of some people health information and its further mention or figuration in mass media. We conclude that it is a must for both physicians and other health team members, to safeguard confidentiality of data to which they have had access, as well as the need to know the relevant law, in order to respect human dignity of patients, each one as a person. We address the attention to the possibility that, practicing in a different way, it could endanger the reliability of clinical records, also impairing the quality of people's health care.

Algunas amenazas actuales a la confidencialidad en medicina / Some current threats to confidentiality in medicine

Social, technical and legal conditions of the current practice of medicine make it necessary to insist on certain actions and circumstances that may jeopardize the confidentiality of information, offered by patients to their health providers. Therefore, some effects of the current Chilean law are analyzed in this respect, regarding access to data from the clinical record of a patient. Also, the risks of putting certain data on social networking sites are analyzed, as well as some of its effects on clinical practice. The reasons because of mandatory reporting of diseases, meaning danger to public health, is allowed, are mentioned. We also discuss the difficulties involved in managing the results of preventative health screenings and its knowledge by third parties, as well as some possible violations of personal privacy, regarding dissemination of some people health information and its further mention or figuration in mass media. We conclude that it is a must for both physicians and other health team members, to safeguard confidentiality of data to which they have had access, as well as the need to know the relevant law, in order to respect human dignity of patients, each one as a person. We address the attention to the possibility that, practicing in a different way, it could endanger the reliability of clinical records, also impairing the quality of people’s health care.

[An ethical and medical perspective on the voluntary termination of pregnancy]. / Consideraciones acerca de la "interrupción voluntaria del embarazo", desde el punto de vista ético-médico (a propósito de un proyecto de ley).

"Voluntary termination of pregnancy" can refer to actions intended to make a delivery easier, to provide medical care to the fetus, or to protect the life or health of the mother. All of these are proper medical actions and are by definition voluntary. In other cases, the expression denotes a termination of pregnancy before the embryo or fetus is viable, leading to the death of the latter. This action is constitutive of abortion under current Chilean law. The product of conception living being, who develops in the womb during pregnancy, is an individual, both in the sense that it is different from its mother and father, and in that it is a biological individual. For these reasons, such living being constitutes another patient in itself. The free and voluntary medical action of health care professionals is geared toward disease prevention or health recovery and medical terminations of pregnancy, as distinguished from abortion, are not criminalized in our country. Therefore, the idea of legalizing abortive terminations of pregnancy so that they become "legitimate health care services" is a call to the medical community, which should engage in a debate about the meaning and consequences of an eventual mandate of the State that would be at odds with the Hippocratic tradition. A woman can feel that her health is at risk due to her pregnancy, and she certainly has the right to request medical help. Health professionals should care both at the medical and emotional level for all those who require their services, especially when such persons are undergoing situations of vulnerability and distress. When requested to perform an abortion, the physician faces dilemmas that should be addressed in line with the present state of the medical art.

Sedación paliativa (parte II): cuestiones éticas y principios morales / Sedação paliativa (parte II): questões éticas e princípios morais / Palliative Sedation (Part II): ethical questions and moral principles

El artículo analiza algunas cuestiones éticas debatidas actualmente en relación con el uso de la sedación al final de la vida, tales como: 1. Si existe una diferencia éticamente relevante entre la sedación paliativa y la eutanasia o el suicidio médicamente asistido; 2. Si el principio del doble efecto tiene aplicación para justificar el recurso a la sedación al final de la vida; 3. Si la sedación paliativa puede ser éticamente apropiada para pacientes que no están en etapa de agonía; 4. Si las decisiones de suspender hidratación y/o nutrición médicamente asistidas son condición necesaria para indicar la sedación; 5. Si la sedación es una respuesta apropiada para el manejo de síntomas psicoespirituales, incluyendo el sufrimiento existencial; 6. Si se puede utilizar la sedación en pacientes incompetentes (i.e. personas incapaces de prestar su consentimiento informado). Para cada una de estas interrogantes se propone una reflexión ético-antropológica, haciendo referencia a algunos principios éticos generales, como la inviolabilidad de la vida humana, el respeto por la dignidad de los moribundos, el principio terapéutico y la proporcionalidad en las terapias, el principio del doble efecto, el respeto por el ejercicio responsable de la libertad (autonomía) y la justicia y la solidaridad.

This article analyzes some of the most controversial ethical questions related to the use of sedation at the end-of-life. Among these questions are: 1. Whether there is an ethically relevant difference between Palliative Sedation (PS) and euthanasia and physician-assisted-suicide; 2. Whether the principle of double effect can be appropriately applied to justify the use of sedation at the end-of-life; 3. Whether PS might be ethically acceptable in the case of patients that are not imminently dying (agony); 4. Whether decisions to limit care and to withdraw medically assisted nutrition and hydration are a necessary condition for PS; 5. Whether sedation is an adequate response to psycho-spiritual symptoms, including ‘existential suffering’; 6. Whether sedation could be used in patients who are not able to give their informed consent (e.g. patients with cognitive impairment of diverse origins, etc.). Ethical- and anthropological reflections are proposed for each of these questions. Reference to some general ethical principles is made, such us: the inviolability of human life; respect for the dignity of the dying; the therapeutic principle and proportionality in medical care; the principle of double effect; respect for a responsible exercise of freedom (autonomy); justice and solidarity.

O artigo analisa algumas questões éticas debatidas atualmente com relação ao uso da sedação no final da vida, tais como: 1. Se existe uma diferença eticamente relevante entre a sedação paliativa e a eutanásia ou o suicídio medicamente assistido; 2. Se o princípio do duplo efeito tem aplicação para justificar o recurso à sedação ao final da vida; 3. Se a sedação paliativa pode ser eticamente apropriada para pacientes que não estão em etapa de agonia; 4. Se as decisões de suspender hidratação e/ou nutrição medicamente assistidas são condição necessária para indicar a sedação; 5. Se a sedação é uma resposta apropriada para o manejo de sintomas psicoespirituais, incluindo o sofrimento existencial; 6. Se é possível utilizar a sedação em pacientes incompetentes (i.e. pessoas incapazes de prestar o seu consentimento informado). Para cada uma destas interrogações se propõe uma reflexão ético-antropológica, fazendo referência a alguns princípios éticos gerais, como a inviolabilidade da vida humana, o respeito pela dignidade dos moribundos, o princípio terapêutico e a proporcionalidade nas terapias, o princípio do duplo efeito, o respeito pelo exercício responsável da liberdade (autonomia), da justiça e da solidariedade.

Sedación paliativa (parte I): controversias sobre términos, definiciones y aplicaciones clínicas / Palliative sedation (part I): controversies about terms, definitions and clinical applications / Sedação paliativa (parte I): controvérsias sobre termos, definições e aplicações clínicas

El artículo analiza el uso de la sedación paliativa como una herramienta terapéutica potencialmente muy útil en Medicina Paliativa. Se propone que, aunque los conocimientos médicos sobre esta práctica clínica han avanzado bastante en la última década, la evidencia empírica disponible sigue siendo limitada y la controversia persiste. El debate actual incluye aspectos como: las definiciones y la terminología a utilizar (sedación paliativa vs. terminal); los tipos de sedación que se incluyen bajo ese término (intermitente vs. continua; superficial vs. profunda); las indicaciones clínicas (síntomas físicos vs. sufrimiento existencial); el uso concomitante vs. la suspensión de la hidratación y la nutrición médicamente asistida, y los fundamentos éticos y su diferencia con la eutanasia y/o el suicidio médicamente asistido. Se revisan algunos aspectos del debate actual sobre el concepto de “sedación paliativa” y sus diferentes definiciones, así como también ciertas controversias relacionadas con sus aplicaciones clínicas. Aunque se mencionan brevemente algunas cuestiones éticas relacionadas con esta práctica clínica, éstas no se abordan directamente en este artículo, sino que se dejan deliberadamente para un análisis más profundo en una segunda parte.

This article analyzes the use of palliative sedation, as a potentially useful therapeutic tool in Palliative Medicine. It suggests that, in spite of the improvement of medical knowledge related to palliative sedation during the last decade, available empirical evidence is still limited and controversy persists. The current debate includes aspects such us: 1. The definition and terminology (palliative vs. terminal sedation); 2. The types of sedation that are included under these expressions (intermittent vs. continuous; superficial vs. profound); 3. The clinical indications (physical symptoms vs. existential suffering); 4. The concomitant administration vs. withdrawal of medically assisted nutrition and hydration; 5. The ethical foundations and its difference with euthanasia and/or physician-assisted-suicide. This article analyzes aspects related to the concept of “palliative sedation” and its different definitions, as well as some controversies related to its clinical applications. Although ethical issues related to palliative sedation are briefly mentioned, they are not dealt with in this article, but intentionally left for a deeper analysis in a part II.

O artigo analisa o uso da sedação paliativa como uma ferramenta terapêutica potencialmente muito útil em Medicina Paliativa. Propõe-se que, ainda que os conhecimentos médicos sobre esta prática clínica tenham avançado bastante na última década, a evidência empírica disponível segue sendo limitada e a controvérsia persiste. O debate atual inclui aspectos como: as definições e a terminologia a ser utilizada (sedação paliativa vs. terminal); os tipos de sedação que são incluidas sob esse termo (intermitente vs. contínua; superficial vs. profunda); as indicações clínicas (sintomas físicos vs. sofrimento existencial); o uso concomitante vs. a suspensão da hidratação e a nutrição medicamente assistida, e os fundamentos éticos e sua diferença com a eutanásia e/ou suicídio medicamente assistido. São revisados alguns aspectos do debate atual sobre o conceito de “sedação paliativa” e suas diferentes definições, assim como também certas controvérsias relacionadas com as suas aplicações clínicas. Ainda que sejam mencionadas brevemente algumas questões éticas relacionadas com esta prática clínica, estas não são abordadas diretamente neste artigo, mas são deixadas deliberadamente para uma análise mais profunda numa segunda parte.

Informe para el Tribunal Constitucional sobre los aspectos científicos y éticos del uso del levonorgestrel como anticonceptivo de emergencia / Report for the Constitutional Court on the scientific and ethical aspects of the use of the levonorgestrel like emergency contraceptive

Las normas de regulación de la fertilidad, propuestas en el documento del Ministerio de Salud de Chile, plantean diversos problemas biomédicos en el contexto de una cierta visión de la procreación humana, de la sexualidad y de la familia. Hay serias objeciones desde una antropología que respeta la naturaleza personal de la mujer y del hombre, especialmente en el riesgo que existe en la promoción de métodos que podrían afectar la vida de seres humanos inocentes en sus etapas iniciales de desarrollo. Del análisis de la literatura se ha concluido que existen antecedentes científicos importantes, que se analizan en este documento, y que indicarían que el uso de la llamada “píldora del día después” podría estar poniendo en riesgo la vida del embrión humano preimplantacional.

Fertility regulation rules, proposed by the Chilean Health Ministry, involve several biomedical problems within the context of a given view point of human procreation, human sexuality and family. There are serious objection from an anthropology that respects the personal nature of woman and man, particularly in the danger that the life and survival of preimplantational human embryo could be affected by such methods. From an exhaustive analysis of the scientific literature, that are discussed in this document, it was concluded that the so called “emergency contraception pill” could be jeopardizing the life and survival of the preimplantation human embryo.

El derecho a morir con dignidad / The right to die with dignity

Partiendo de una reflexión sobre los significados divergentes que se atribuyen hoy al llamado ôderecho a morir con dignidadõ, el trabajo analiza la respuesta que ofrece la Medicina Paliativa al debate sobre el final de la vida humana. Luego de revisar las estadísticas actualmente disponibles en Holanda ùprimer país en despenalizar la eutanasiaù, la autora expone la solución que ha dado la Medicina Paliativa a la problemática de la ômuerte dignaõ. Para comprender adecuadamente esta respuesta, es necesario entender el acto de morir como un ôacto humanoõ. En ese contexto, la autora menciona cinco principios morales que considera especialmente relevantes para resguardar la dimensión ética del morir. Ellos son: el principio de veracidad, de proporcionalidad terapéutica,del doble efecto, de prevención y de no-abandono. El trabajo concluye con una invitación a cambiar el actual paradigma médico, pasando de una medicina dominada por la lógica del ôimperativo tecnológicoõhacia una ômedicina personalistaõ.

Resultado de cardioversión eléctrica en pacientes con fibrilación auricular idiopática y secundaria a enfermedad reumática / Cardioversion in patients with atrial fibrillation

Cicuenta y siete pacientes portadores de fibrilación auricular fueron sometidos a cardioversión eléctrica electiva. En función de la cardiopatía basal, los pacientes se clasificaron en 3 grupos: fibriladores crónicos con valvulopatía no operada (11), fibriladores crónicos con valvulopatía operada (29) y fibriladores idiopáticos (12). El éxito inmediato de la cardioversión fluctuó entre 82 y 92% para los 3 grupos. El éxito alejado (11.9 +- 4.5 meses) disminuyó a un 27% para los valvulares no operados, a un 24% para los valvulares operados y a un 75% para los idiopáticos. Factores determinantes de éxito o fracaso, además de la patología de base, fueron la presencia de insuficiencia cardíaca y el tamaño de la aurícula izquierda. Concluimos que la cardioversión eléctrica tiene un éxito alejado pobre en pacientes valvulópatas y un éxito satisfactorio en pacientes sin otra evidencia de patología cardíaca